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Global valve-in-valve registry reveals main complications

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SAN FRANCISCO — While aortic valve-in-valve is an effective overall procedure, malpositioning, ostial coronary occlusion and residual stenosis are three main problems identified in a global registry of aortic valve-in-valve procedures, according to a speaker at TCT 2013.

Danny Dvir, MD, from St. Paul’s Hospital, Vancouver, B.C., Canada, presented the latest findings from the Valve-in-Valve International Data (VIVID) Registry.

The registry is looking at 742 patients who underwent valve-in-valve procedures at 69 sites in Europe, North America, Australia, New Zealand, South Africa, South America and the Middle East. Of those, 554 underwent aortic valve-in-valve procedures and 188 underwent either isolated mitral valve-in-valve procedures or isolated tricuspid valve-in-valve procedures.

Malpositioning

Of the three main issues Dvir identified, device malpositioning occurred more often at the beginning of the learning curve with the procedure (14.4% vs. 9% after the seventh case of the procedure; P=.046). It was also more common in regurgitant bioprostheses (13.3% vs. 7.2% in bioprostheses with isolated isolated stenosis; P=.04). In addition, malpositioning was also more common in inside stentless and Mosaic stented valves (16.1% and 14% vs. 9% in non-Mosaic stented valves; P=.04). However, Dvir noted, there was no difference in the malposition rate between transfemoral vs. transapical procedures (4.1% vs. 7%; P=.39).

“This is something we did not expect,” Dvir said.

Ostial coronary obstruction

Ostial coronary obstruction was another main issue, according to Dvir. It occurred in 3.9% of stenosis cases and 0.8% of regurgitation cases (P=.02).

“I can say that the rate of ostial coronary obstruction is going down,” he said. The key to avoiding coronary obstruction is being meticulous in pre-procedural screening.

Residual stenosis

Another main issue with valve-in-valve procedures is residual stenosis.

“I can expect that the malposition rate will go down with the learning curve issues resolved, and ostial occlusion will go down as well, but we will be left in several years with the issue of residual stenosis,” Dvir said. “The mean gradients after aortic valve-in-valve procedure are high.” The measurements in the stenosis group were 18.4 ± 9.8 mm Hg, 12 ± 6.7 mm Hg in the regurgitation group and 16 ± 8.3 in the combined group (P<.001).

Dvir revealed that there are a number of projects in progress with the global valve-in-valve registry and he expects there will be much more information to share at next year’s TCT meeting.

For more information:

Dvir D. Insights from the Worldwide Valve-in-Valve TAVR registry. Presented at: TCT 2013; Oct. 27-Nov. 1, 2013; San Francisco.

Disclosure: Dvir reports no relevant financial interests to disclose.